title: Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials.
abstract: OBJECTIVE
  To critically evaluate any benefit or harm for the mother and her baby of Valsalva pushing versus spontaneous pushing in the second stage of labour.
  
  
  METHODS
  Electronic databases from MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were systematically searched (last search May 2010). The reference lists of retrieved studies were searched by hand and an internet hand search of master theses and dissertations was performed. No date or language restriction was used.
  
  
  METHODS
  Randomised controlled trials that compared instructed pushing with spontaneous pushing in the second stage of labour were considered. Studies were evaluated independently for methodological quality and appropriateness for inclusion by two authors (MP and JB).
  
  
  METHODS
  The primary outcome was instrumental/operative delivery. Other outcomes were length of labour, any perineal repair, bladder function, maternal satisfaction. Infant outcomes included low Apgar score < 7 after 5 minutes, umbilical arterial pH <7.2, admission to neonatal intensive care unit and serious neonatal morbidity or perinatal death.
  
  
  RESULTS
  Three randomised controlled studies covering 425 primiparous women met the inclusion criteria. Women who used epidural analgesia were excluded in all three studies. No statistical difference was identified in the number of instrumental/operative deliveries (three studies; 425 women; relative risk 0.70; 95% CI 0.34-1.43), perineal repair, postpartum haemorrhage. Length of labour was significantly shorter in women who used the Valsalva pushing technique (three studies; 425 women; mean difference 18.59 minutes; 95% CI 0.46-36.73 minutes). Neonatal outcomes did not differ significantly. Urodynamic factors measured 3 months postpartum were negatively affected by Valsalva pushing. Measures of first urge to void and bladder capacity were decreased (one study; 128 women; mean difference respectively 41.50 ml, 95% CI 8.40-74.60, and 54.60 ml, 95% CI 13.31-95.89).
  
  
  CONCLUSIONS
  The evidence from our review does not support the routine use of Valsalva pushing in the second stage of labour. The Valsalva pushing method has a negative effect on urodynamic factors according to one study. The duration of the second stage of labour is shorter with Valsalva pushing but the clinical significance of this finding is uncertain. The primary studies are sparse, diverse and some flawed. Further research seems warranted. In the mean time supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.
authors.affiliation: Department of Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands. marianne.prins@inholland.nl
authors.forename: M
authors.initials: M
authors.lastname: Prins
authors.forename: J
authors.initials: J
authors.lastname: Boxem
authors.forename: C
authors.initials: C
authors.lastname: Lucas
authors.forename: E
authors.initials: E
authors.lastname: Hutton
mesh_terms: D001034:Apgar Score; D036861:Delivery, Obstetric / Q000379:methods*; D005260:Female; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007231:Infant, Newborn; D007748:Labor Stage, Second / Q000502:physiology*; D007744:Obstetric Labor Complications / Q000209:etiology*; D011247:Pregnancy; D011256:Pregnancy Outcome; D016032:Randomized Controlled Trials as Topic; D012151:Resuscitation / Q000706:statistics & numerical data; D014469:Umbilical Arteries; D014636:Valsalva Maneuver / Q000502:physiology*